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Pancreatic enzyme replacements: Nursing Pharmacology



pancrelipase (Creon, Pancreaze, Viokace, Zenpep)
Pancreatic enzyme replacement
Contain pancreatic enzymes (amylase, protease, lipase) to help digest food in the intestines
  • Cystic fibrosis
  • Pancreatic duct obstruction
  • Pancreatectomy
  • Gastric and intestinal resection surgeries
  • Headache
  • Ear pain
  • Nasal congestion
  • Cough
  • Abdominal pain
  • Nausea
  • Vomiting
  • Flatulence
  • Constipation
  • Diarrhea
  • Altered blood glucose
  • Dizziness
  • Epistaxis
  • Gallstones
  • Pruritus
  • Pruritus ani
  • Hypersensitivity to porcine products
  • Pregnancy and breastfeeding
  • Crohn disease
  • Pancreatitis
  • Diabetes mellitus
  • Past and current gastrointestinal symptoms; e.g., abdominal pain and cramping after meals, indigestion, vomiting, and steatorrhea
  • Nutritional intake, food preferences, typical daily diet, recent weight loss
  • Weight, vital signs; observe for signs of hypotension, dehydration
  • Laboratory test results: albumin, calcium, magnesium, phosphate, glucose, uric acid, vitamin D, E, and B12 levels; fecal fat and elastase
  • Monitor
    • Side effects; e.g., headache, flatulence, abdominal pain, constipation, diarrhea; elevated uric acid, hyperglycemia
    • Manifestations of malabsorption like decreasing weight, steatorrhea, osteoporosis
  • Evaluate for desired outcomes: resolution of symptoms
  • How the medication improves digestion and decreases symptoms
  • Take the medication with every meal or snack
  • Swallow whole without crushing or chewing
  • Separate antacids and pancreatic enzymes by two hours
  • Dietary modifications
    • Small, frequent meals
    • Nutrient dense, high in protein, and low in fat
    • Whole grains, fruits, and vegetables
    • Avoid refined sugar and fatty foods
    • Abstain from alcohol and smoking
  • Recognize steatorrhea: pale, loose, malodorous, stools
  • Report
    • Persistence of side effects
    • Symptoms of elevated uric acid levels; e.g., painful, swollen joints
    • Symptoms of hyperglycemia; e.g., frequent urination and increased thirst and appetite

Pancreatic enzyme replacement therapy is the administration of digestive enzymes that are normally produced by the pancreas to digest food. Pancreatic enzyme replacement is primarily used in conditions that result in pancreatic enzyme deficiency, such as cystic fibrosis, chronic pancreatitis, pancreatic duct obstruction like by tumors, and surgeries like pancreatectomy. Additionally, it can be used in conditions that cause insufficient secretion of pancreatic enzymes, such as gastric and intestinal resection surgeries. 

The main pancreatic enzyme replacement available is pancrelipase, which can be administered orally, immediately before or with a meal or snack. Now, the medication is covered with an enteric coat that protects them from gastric acid, so they can safely reach the duodenum. Once there, the tablet coat dissolves in the alkaline environment and releases the replacement enzymes, which perform the function normally accomplished by pancreatic enzymes. These include amylase, proteases, and lipase. Amylase digest carbohydrates into smaller units of glucose molecules. On the other hand, proteases include trypsin and chymotrypsin, which break down proteins into amino acids. Finally, lipase digests lipids like triglycerides into glycerol and fatty acids. These smaller molecules are then absorbed across the intestinal cells into the bloodstream. 

Now, pancreatic enzyme replacement therapy is generally safe and well tolerated. However, some clients may experience gastrointestinal side effects like abdominal pain, nausea and vomiting, flatulence, constipation, or diarrhea. Pancreatic enzyme replacement can also affect blood glucose level, so these clients should undergo frequent blood glucose monitoring. Other side effects include headaches, ear pain, nasal congestion, and a cough. Less common side effects include dizziness, epistaxis, gallstones, and pruritus, such as pruritus ani due to irritation of the skin around the anus.

Pancreatic enzyme replacement is extracted from pig pancreas, so it is contraindicated in clients with hypersensitivity to porcine products. In addition, as a precaution, it should not be used during pregnancy and breastfeeding. Finally, pancreatic enzyme replacement therapy should be used with caution in clients with Crohn disease, pancreatitis, or diabetes mellitus

Now, if your client with chronic pancreatitis is prescribed pancreatic enzyme replacement, first obtain a focused health history and assessment. Ask about past and current gastrointestinal symptoms, such as abdominal pain and cramping after meals, indigestion, vomiting, and steatorrhea, or fatty stools. Also ask about their nutritional intake, food preferences, and typical daily diet, as well as recent weight loss. Then, assess your client's weight and vital signs, observing for signs of hypotension or dehydration. Lastly, note recent laboratory test results, including albumin, calcium, magnesium, phosphate, glucose, uric acid, as well as vitamin D, E, and B12 levels; and note the results of tests for fecal fat and elastase.